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What causes a pure-tissue hernia repair to fail? And how?
What is it the actual failure mechanism of a pure-tissue hernia repair that causes it to fail? What is the weak point of the repair? Aren’t the muscles just being sewn back together, so wouldn’t the muscle regrow to itself and combined with scar tissue hold it together?
Does the muscle tear? Does the tissue itself rip or tear?
Do the sutures pop or come undone? Is that why Shouldice (supposedly) uses stainless-steel sutures?
Does the standard plastic suture eventually degrade and fail, causing the original hernia opening to return?
Is it because of an unsatisfactory repair or lack of practice of the surgeon?
I am trying to better understand the mechanism of failure for pure-tissue hernia repairs, but I haven’t found a great resource online that explains it.
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29 Replies
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Torn ACL are not always replaced. With ARP WAVE, they are merely allowed to healed back over as much as possible, then the ARP WAVE square wave current is sent thru the ligament to eradicate excess scar tissue, create flexibility, enhance complete healing, and strengthen weak auxiliary supportive muscles, tendons, ligaments. Football players go out and play again with their same speed and strength with this type of treatment vs grabbing a ligament from a cadaver or another part of the body.
When you are older, the ACL heals slower and you heal with different type of collagen, not collagen type I or II like a child or teenager,but Type III. Ex. Barry Bonds(never ACL, just hamstrings) though terrific using steroids to enhance his home run hitting ability, kept getting hamstring pulls, and could not continue at 39 vs 35 years of age fielding and hitting well. Consequently, you need some treatment like this or other less modern techniques before the ligament can be used again to run.
Note: I am emailing Denis Thompson of Arp Wave just how far he can go in helping small hernias heal beforehand or assisting in complications after surgery. Again, I believe that regenerative modalites like PRP and Prolo Ozone, ARP Wave, and good nutritional supplementation can have a role in the post-success of hernias at least, if not prior.
Obviously, Sclerotherapy or Prolotherapy were used with some success in the far past to heal hernias, so it could be used as post-treatment as well.
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I believe also Testosterone replacement in older men..would help greatly !
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My understanding is also that the original Shouldice technique relied on a steel wire for suturing. I later learned that most of the surgeons that do the Shouldice technique use a modified version of it, unless we are talking about the Shouldice Clinic where a steel wire is still used. But what kind of suture do these other surgeons use when they do the Shouldice technique?
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quote saro:interesting theory against current (nonconformist)
Yep..Drug companies will not like it :}
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I had ventral (with an umbilical component ) surgery with Dr. Tomas on September 7th.
My defect was about the size of a dime.
He used Ethibond sutures for my defect using 3 layered suturing, vertical mattress technique. For my incision he used absorbable sutures.
He states on his website that he has “a low recurrence rate, less than 4% for ventral hernias”.
I will give an update in the future. -
quote drkang:What you’ are saying is to some extent true concerning femoral hernia, umbilical hernia or incisional hernia. That is because for these types of hernias, the margin of the hernia hole is composed of ligaments or ligament-like fibrous tissue. This leads to the possibility of recurrence as the hard and inelastic tissue may tear after tissue repair. Despite this, based on my personal experience, the majority cases of femoral hernia and umbilical hernia with less than 2cm in diameter underwent pure tissue repair without recurrence.
It is however very different for the circumstances of inguinal hernia. The defect margin of inguinal hernia is composed of soft and elastic muscle instead of hard ligamentous tissue. And, not only for indirect hernia but for direct types of hernia as well, almost all cases have only a definite single defect. Thus, pure tissue repair can be performed on inguinal hernia for all patients very successfully. The high recurrence rate that existing tissue repairs have is not because of a tissue problem but because they are not the ideal surgical methods.
Therefore, what I believe was needed to solve the high recurrence rate of previous tissue repairs was not a surgery that uses durable mesh as reinforcement but rather the development of a new ideal tissue repair method. I think that the fundamental approach of solving the mesh problem is even now leaving aside the attempt to develop a so-called safe mesh and instead come up with a new optimal tissue repair method.
iI apologize if one day I understand one thing and the other the opposite .. now I read again the very interesting thesis, but I don’t understand if the conclusion suggests to study pure mesh or tissue repair
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Baris What breand of vitamin C are you taking ?
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Hi Good intentions,
I understand that it is not easy for the non-medical people to understand the anatomy of inguinal area which is also difficult even for the medical personels to understand fully. I respect many participants here including you who are very dedicated and have very precise knowledge about hernia repair and mesh problem sometimes more than doctors do. I also frequently learn something and get the useful information from many of you. That is why I sometimes visit this forum and look around.
Thank all of you for that.
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Thank you for the correction Dr. Kang. I know very little about the anatomy of the groin. I should have learned more about tissue repairs in general before making that post. Most of my thinking has been about mesh and how it’s used since that’s how my direct hernia was repaired, before I had it removed.
Thank you for staying in touch with the forum and good luck with your efforts. I look forward to your posts.
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quote Good intentions:I can’t add anything very specific to why “pure” tissue repairs fail, but I have realized that one of the difficulties with hernia repair is that the tissue that fails is not normally injured so does not have a robust healing mechanism. It is very like an ACL tear of the knee, which can only be repaired well by replacing it entirely. That’s why, I think, they call mesh a prosthetic. It’s an aponeurosis replacement. The pure tissue repairs are attempts to tie a “ligament” back together. It doesn’t work well.
The aponeurosis is essentially a wide flat ligament, at the ends of the abdominal muscles. I supplied the Wikipedia link below. Each suture point in the ligament is a new hole that can elongate and tear. That’s why Shouldice uses so many, to spread the load across many holes. There are some basic engineering principles involved. It is a lot like darning a sock or a pair of Levis. More sutures are better. To avoid that, many of the multitude of repair techniques involve moving tissue that heals, over, to take the place of the failed aponeurosis, which will, essentially, never really “heal”. As I understand things.
What you’ are saying is to some extent true concerning femoral hernia, umbilical hernia or incisional hernia. That is because for these types of hernias, the margin of the hernia hole is composed of ligaments or ligament-like fibrous tissue. This leads to the possibility of recurrence as the hard and inelastic tissue may tear after tissue repair. Despite this, based on my personal experience, the majority cases of femoral hernia and umbilical hernia with less than 2cm in diameter underwent pure tissue repair without recurrence.
It is however very different for the circumstances of inguinal hernia. The defect margin of inguinal hernia is composed of soft and elastic muscle instead of hard ligamentous tissue. And, not only for indirect hernia but for direct types of hernia as well, almost all cases have only a definite single defect. Thus, pure tissue repair can be performed on inguinal hernia for all patients very successfully. The high recurrence rate that existing tissue repairs have is not because of a tissue problem but because they are not the ideal surgical methods.
Therefore, what I believe was needed to solve the high recurrence rate of previous tissue repairs was not a surgery that uses durable mesh as reinforcement but rather the development of a new ideal tissue repair method. I think that the fundamental approach of solving the mesh problem is even now leaving aside the attempt to develop a so-called safe mesh and instead come up with a new optimal tissue repair method.
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I can’t add anything very specific to why “pure” tissue repairs fail, but I have realized that one of the difficulties with hernia repair is that the tissue that fails is not normally injured so does not have a robust healing mechanism. It is very like an ACL tear of the knee, which can only be repaired well by replacing it entirely. That’s why, I think, they call mesh a prosthetic. It’s an aponeurosis replacement. The pure tissue repairs are attempts to tie a “ligament” back together. It doesn’t work well.
The aponeurosis is essentially a wide flat ligament, at the ends of the abdominal muscles. I supplied the Wikipedia link below. Each suture point in the ligament is a new hole that can elongate and tear. That’s why Shouldice uses so many, to spread the load across many holes. There are some basic engineering principles involved. It is a lot like darning a sock or a pair of Levis. More sutures are better. To avoid that, many of the multitude of repair techniques involve moving tissue that heals, over, to take the place of the failed aponeurosis, which will, essentially, never really “heal”. As I understand things.
Just another way to look at things. The more I learn the more complicated things seem. I can understand the attempts to simplify that have led to this huge mesh problem.
https://en.wikipedia.org/wiki/Aponeurosis
UhOh!’s recent topic and link is very relevant to this topic.
https://www.herniatalk.com/8458-guarnieri-technique-and-hernia-center
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quote drkang:It has been a while since I am writing.
In reality, I believe this topic is the key inquiry concerning inguinal hernia repair. The reason being, pure tissue repair in the past had high failure rate, which caused the introduction of mesh repair to be performed worldwide. This resulted into mesh complications. Therefore, if it is possible to find the exact cause of tissue repair failure and develop a new repair method that is reliable not to fail, the risky use of mesh will not be necessary.
The problem here is that it is not easy to identify the reason of failure of tissue repairs. Many would think that research will eventually reveal the cause. However, considering all the variables in research, it is almost impossible realistically to exactly pinpoint the cause. So, the most realistic approach is for a doctor with deep interest in solving the issue to set a hypothesis for the cause of failure and see if it works by performing the method devised on the hypothesis.
Hypotheses for the cause can differ based on the experiences and inspiration of each doctor. Dr. Lichtenstein and those who support his method claim that repair failure is caused by the weakening and tearing of tissue after the repair. Doctors who prefer laparoscopic mesh repair also agree on the tearing of tissue as a cause of failure after the repair and that it is important to implant mesh in the inside of the hernia defect in order to reduce failure rate.
Dr. Desarda seems to agree with doctors that perform mesh repair as well. Except that to avoid mesh complications, the patient¡¯s strip of external oblique aponeurosis is used instead of mesh in his operation.
On the other hand, Dr. Shouldice seemed to have a different opinion. He seemed to believe the insufficient tissue repair methods of the past were the main cause of recurrence. So he developed his own quite meticulous and extensive method.
However, it appears as though the Shouldice hospital carefully selects patients eligible to undergo their repairs. According to posts on this forum, patients who recurred since less than a year ago are not subject to the repair and obese patients are required to lose weight. Patients with early stage inguinal hernia when the bulging is not grossly visible are excluded from the eligible list. At first glance, it may look as though carefully selecting eligible patients is for the better of the patients. However, I also see it as a way to maintain their good surgery outcome. Excluding high-risk patients and selecting only low-risk patients will definitely result in favorable and consistent outcomes. Likewise, frankly speaking, doctors mentioning smoking, collagen deficit, and chronic cough etc. as factors increasing hernia recurrence could be making excuses to defend themselves.
I believe that rather than strictly and selectively performing surgery on patients in accordance to the various problems they have, there should be a tissue repair method that will bring successful results to high risk patients as well. Below are what I believe to be the three main problems of existing tissue repair methods that cause high failure rate.
The first problem is performing the same or similar method for both indirect and direct inguinal hernia without distinction.
Second, suture closure is not directly done on the hernia opening.
Third, the hernia sac is not mobilized sufficiently to push it back into its original location.
These three aspects are my personal hypothesis on the cause of tissue repair failure. Therefore, I have developed and am currently in conduct of a new pure tissue repair method where the hernia sac is sufficiently mobilized to restore it back into its original location, specific methods ideal for each direct and indirect type is used, and suture closure is directly done on the hernia opening. For the whole time, I haven¡¯t selected patients relatively ¡°safe¡± to treat nor rejected patients with high risk factors to perform my method on. From my experience until now, I can say that the various high risk factors have little to no influence like taking from or adding a cup of water to a fully filled bath tub.
Factors that are considered high risk are in fact mere aspects of life to many people. Rather than demanding patients to modify their life to the surgery, it is necessary to develop the surgical method to cover the way one¡¯s lifestyle is. Accordingly, an ideal tissue repair should be able to give successful results consistently despite whatever risk factor that the patient may hold.
Thus, I believe the essential reason for tissue repair failure is because existing methods are not impeccable.
I always like reading your explanations for things on here! It sounds as though the first and second problems may be related; a one-size-fits-all approach would not account for the need to close different types of defects (a tear in the case of direct, and a widening of the interior ring in the case of indirect). Using a single approach would also have to presuppose that the damaged tissue itself will not be repairable and there is a need to use the body’s other tissue to “compensate.”
The first part of your hypothesis, about use of a single tissue repair method for all surgeries leading to higher failure rates, should (theoretically) be testable through a retrospective study, assuming the surgery notes from each patient specified the nature of the hernia (direct or indirect) and gave at least some description of the technique used.
Perhaps the high overall failure rate would be broken down into a very low rate when the technique was appropriate for the hernia type, and an astronomical rate when an inappropriate technique was used. The good news is that it would seem this type of study could be organized with minimal notes from each surgery, and could offer some useful findings even if there was not sufficient information in those notes to speak to problems two and three above.
I’m going to try and get ultrasound imaging of mine done in the coming weeks and it will be interesting to see how that impacts my decision as to whether or not to seek a repair, and a surgeon’s suggestion of one technique over another.
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It has been a while since I am writing.
In reality, I believe this topic is the key inquiry concerning inguinal hernia repair. The reason being, pure tissue repair in the past had high failure rate, which caused the introduction of mesh repair to be performed worldwide. This resulted into mesh complications. Therefore, if it is possible to find the exact cause of tissue repair failure and develop a new repair method that is reliable not to fail, the risky use of mesh will not be necessary.
The problem here is that it is not easy to identify the reason of failure of tissue repairs. Many would think that research will eventually reveal the cause. However, considering all the variables in research, it is almost impossible realistically to exactly pinpoint the cause. So, the most realistic approach is for a doctor with deep interest in solving the issue to set a hypothesis for the cause of failure and see if it works by performing the method devised on the hypothesis.
Hypotheses for the cause can differ based on the experiences and inspiration of each doctor. Dr. Lichtenstein and those who support his method claim that repair failure is caused by the weakening and tearing of tissue after the repair. Doctors who prefer laparoscopic mesh repair also agree on the tearing of tissue as a cause of failure after the repair and that it is important to implant mesh in the inside of the hernia defect in order to reduce failure rate.
Dr. Desarda seems to agree with doctors that perform mesh repair as well. Except that to avoid mesh complications, the patient¡¯s strip of external oblique aponeurosis is used instead of mesh in his operation.
On the other hand, Dr. Shouldice seemed to have a different opinion. He seemed to believe the insufficient tissue repair methods of the past were the main cause of recurrence. So he developed his own quite meticulous and extensive method.
However, it appears as though the Shouldice hospital carefully selects patients eligible to undergo their repairs. According to posts on this forum, patients who recurred since less than a year ago are not subject to the repair and obese patients are required to lose weight. Patients with early stage inguinal hernia when the bulging is not grossly visible are excluded from the eligible list. At first glance, it may look as though carefully selecting eligible patients is for the better of the patients. However, I also see it as a way to maintain their good surgery outcome. Excluding high-risk patients and selecting only low-risk patients will definitely result in favorable and consistent outcomes. Likewise, frankly speaking, doctors mentioning smoking, collagen deficit, and chronic cough etc. as factors increasing hernia recurrence could be making excuses to defend themselves.
I believe that rather than strictly and selectively performing surgery on patients in accordance to the various problems they have, there should be a tissue repair method that will bring successful results to high risk patients as well. Below are what I believe to be the three main problems of existing tissue repair methods that cause high failure rate.
The first problem is performing the same or similar method for both indirect and direct inguinal hernia without distinction.
Second, suture closure is not directly done on the hernia opening.
Third, the hernia sac is not mobilized sufficiently to push it back into its original location.
These three aspects are my personal hypothesis on the cause of tissue repair failure. Therefore, I have developed and am currently in conduct of a new pure tissue repair method where the hernia sac is sufficiently mobilized to restore it back into its original location, specific methods ideal for each direct and indirect type is used, and suture closure is directly done on the hernia opening. For the whole time, I haven¡¯t selected patients relatively ¡°safe¡± to treat nor rejected patients with high risk factors to perform my method on. From my experience until now, I can say that the various high risk factors have little to no influence like taking from or adding a cup of water to a fully filled bath tub.
Factors that are considered high risk are in fact mere aspects of life to many people. Rather than demanding patients to modify their life to the surgery, it is necessary to develop the surgical method to cover the way one¡¯s lifestyle is. Accordingly, an ideal tissue repair should be able to give successful results consistently despite whatever risk factor that the patient may hold.
Thus, I believe the essential reason for tissue repair failure is because existing methods are not impeccable.
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A few weeks before my surgery i am advised to take vitamin c every time i have a meal as they say at the shouldice clinic it enables a better repair and recovery. Ive had surgery before for a dental procedure and i was put on an IV of vitamin C and ive never recovered that quickly. Felt like i was never on the chair. Whenever i have an injury i take vitamin c and it definently helps my recovery. I ruptured my hamstring ( about 19cms) i quickly went on an iv and took dosages of vitamin C and my physio was amazed at the recovery time and how soon i was able to return to competitive sports. I denfinently think vitamin c is needed prior to any surgery but ensure a lot of fluid is taken in as it can cause constipation and thats not ideal especially if your having hernia surgery.
Also i have heard of many doctors that smoking can cause collagen issues.
in regards to exercise although it can be painful i have started strengthening my abdominal muscles for the surgery. Is this a good idea? Would it be beneficial? -
Collagen Complete contains vitamin C, hyaluronic acid and hydrolyzed collagen. Each of these ingredients protect collagen production, stimulate collagen production, or do both. Let’s examine how each of these essential ingredients works to the benefit of your skin, hair, bones, and joints:
- Vitamin C – Vitamin C is used to make all 18 types of collagen found in the body. It combines with lysine and proline, two amino acids, to form the first precursor of collagen, known as “procollagen.” As an antioxidant, vitamin C also protects existing collagen from damage.
- Hyaluronic Acid – Hyaluronic acid occurs naturally in the body and regulates and repairs cell growth. It is found in connective tissues and is needed to bind collagen and elastin. By doing so, it increases elasticity and protects cartilage throughout the body as well as the skin.
- Hydrolyzed Collagen – Hydrolyzed collagen contains amino acids, including glycine, proline, and lysine, which the body uses to build connective tissue and regulate cell growth. This offers comprehensive, collagen-related benefits to the hair, skin tissue, muscle, cartilage, ligaments, and blood cells.
- Other Antioxidants – Antioxidants such as vitamin E, rosehip, and acerola cherry can also protect existing collagen from free radical damage. You’re regularly exposed to free radicals through the body’s normal processes (like digestion), as the body breaks down medicine, and through environmental pollutants. By consuming fruits, vegetables, and supplements with a wide range of antioxidants, you can protect against this damage.
Poor sleep has long been connected with increased stress hormones, which increases inflammation in the body. This can exacerbate existing skin problems, including the breakdown of both collagen and hyaluronic acid. As we mentioned above, both of these molecules are responsible for a glowing, healthy complexion and a reduction in fine lines and other age-related issues. To put it simply: The longer you’re asleep, the more time you give your body to produce more collagen and hyaluronic acid.
Studies have also found a connection between sleep and the production of human growth hormone (HGH). Without sufficient levels of HGH in the body, it’s common to experience issues such as lower cell reproduction as well as growth problems. Adequate sleep helps combat these issues because the body secretes the most HGH shortly after the onset of sleep and continues through the first phase of slow-wave sleep. And, because HGH stimulates collagen production in muscles and tendons, sleep is necessary for the body to repair, rebuild, and refresh each night.
If you struggle to fall or stay asleep, there are steps you can take to improve the quality of your rest. Many natural ingredients, including melatonin, passionflower extract, valerian root, and GABA, can help with this.
Consider the benefits of each:
- Melatonin – The pineal gland secretes melatonin when the body is exposed to lower levels of light, especially at night between 2 and 5 am. Melatonin regulates circadian rhythms and is commonly used as a sleep aid.
- Passionflower Extract – Passionflower extract is a well-known sedative that stops muscle spasms, calms the mind, and helps those who feel anxious fall and stay asleep.
- Valerian Root – Valerian is a tall, flowering grassland plant that is known to reduce the time it takes to fall asleep and may help individuals sleep better. Nervous, anxious, and depressed individuals benefit most from valerian, as do those with epilepsy, ADHD, or Chronic Fatigue Syndrome.
- GABA – GABA is a natural neurotransmitter that reduces anxiety while increasing alpha waves in the brain. It is often used to prevent insomnia, combat restlessness, and works against muscle spasms.
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While treating me, Dr. Towfigh has figured out that I have a collagen disorder. I haven’t been to a rheumatologist for an official diagnosis, but may do that in the future. I have had multiple recurrent hernias and tissue repairs fail and have other symptoms suggestive of a collagen disorder, so Dr. Towfigh has treated me as she would someone with a diagnosed collagen problem. I have certainly asked what I can be doing to improve my collagen and quality of my tissues and the answer so far has been nothing. I don’t know of any supplements that have been proven to help with this type of problem. I am taking a collagen supplement, not sure if it helps with this sort of issue but I figured it can’t hurt. Maybe I’ll have nice skin and nails from it! Haha. A person with a true collagen disorder does not do well with pure tissue repairs because our tissues are weak and do not heal like healthy tissue and peritoneum. I am not over weight so that has not contributed to my problem. I would like to know the answer to the question, as well, if weight gain alone contributes to recurrence. If anyone knows of diet and exercise that help improve collagen I would love to hear it! I am having ultrasound therapy from PT for now to help with healing from surgery and reduce scar tissue. Figured that can’t hurt either. I am open to any advice and suggestions since I am slow to heal and seem to have an unusual amount of swelling for a long time after surgery.
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quote drtowfigh:The original Shouldice repair was described with stainless steel suture. Most of us do not use that anymore. At the Shouldice hospital, they still use stainless steel because it’s cheaper—that’s what they told me. They make their own sutures in the back room. I saw their technicians do so. They have a limited stipend provided by the government Lee patient so they have a lot of cost cutting steps. Suture is one of them.
The reason why tissue repairs fail is often because of the quality of the tissue being sewn. Most with inguinal hernias have a collagen deficit. Sewing collagen deficient tissue together is less sturdy than healthy tissue.
Interesting, thank you for this information [USER=”935″]drtowfigh[/USER]
The next obvious question then is; how can patients increase the quality of their own tissue and/or collagen? Does exercise, healthy diet, and weight loss into a healthy BMI range achieve this?
As [USER=”2468″]Baris[/USER] mentions the Shouldice clinic is known to routinely suggest diets and weight loss to patients who are overweight before they will do a surgery, so perhaps there is some validity to a dietary approach. I suppose the question then becomes is if the successful outcome is then dependent on maintaining that weight loss, and if weight gain alone would contribute to recurrence?
In my mind I think of a lean cut of steak versus a marbled fatty steak, I wonder if that is is basically reflective of what the muscle tissues resembles of a lean vs obese patient.
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I certainly think so. The shouldice surgeon stated that preparation was as important as on the day of the surgery. A whole load of diatery changes were given to ensure your prepared for surgery in the best way possible. I had a shouldice procedure (absorbable sutures) before and i went in their weighing 107kg. When i requested surgery at the shouldice clinic after reoccurence they told me to come in at a maximum of 89kg or theres a big chance id be sent back home. When i asked them why and that i had the surgery weighing 107kg, they said that it allows them to complete a better repair as fat around muscle tissue contributes to a weaker outcome and finish. It also ensures a less painful and better recovery i was told.
So when thinking about it even a simple change in a pre surgical procedure contributes to a better outcome. -
I also wonder whether pre-surgical workflows matter more than are given credit for. Both Shouldice and Dr. Kang, for example, seem to see high volumes of hernia repair patients and have established workflows seemingly nonexistent elsewhere.
The first time I heard of Shouldice was in business school; it was the subject of a case study used in an operations class. While their procedure seems quite effective, I’d be willing to bet that the pre-surgical workflows have something to do with why nobody else can replicate their low recurrence rate when using the same technique.
And then there’s Dr. Kang. While not discounting the improvements he seems to have made to pure tissue repair techniques, a big part of his innovation would seem to be workflow-related. The addition of US imaging as a precursor to every single surgery allows a defect-specific procedure (and incision location) to be selected in advance and, I would imagine, minimize the need to improvise during surgery to account for unanticipated findings.Another thought: Is it possible that pre-surgical workflows have a greater impact on the outcome than they’re given credit for?
[USER=”2019″]drkang[/USER] can certainly weigh in, though not sure if any Shouldice docs here to comment.
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Also Dr Brawn told me that thank to drtowfigh he using a lot of her natural pain inflammation cooling supplements after surgery !
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